The following is a guest article by Greg Sanders, MD, FACC and Founder of HybridChart.
Most companies strive for efficiency with a mission of continuous process improvement. This is a good way to lower overhead costs and reduce errors or waste. The ultimate goal is a higher level of satisfaction among customers and employees. Most industries have made significant progress in streamlining their internal workflows, so it is baffling to me how medicine seems to be stuck in a gridlock of poorly assembled methods, with a knee-jerk resistance to change.
You can only assume that doctors want that same improvement in satisfaction for their patients and for the brave souls who run the front and back office of medical clinics. Doctors also seem keen on trying the latest and greatest when it comes to therapeutics and new-age diagnostics. Yet somehow the thought of creating sensible workflows that everyone can agree upon is unthinkable.
This Is How It Has Always Been Done
Part of the problem lies in our training. In medical school residency rotations typically last a month. We have all started a rotation and been told, “This is how we do it,” referring to rounds, or some component of the workflow. And we have all at one time said to ourselves, “Why on earth would we do it this way?” But alas, it is just for one month, and we do not want to be labeled as disruptive on our evaluations.
Once we end up in practice, this deep seated ability to shrug our shoulders and go with the existing process is our default emotion. We are focused on taking care of patients, learning the dreaded EHR, and making sure we can find our parking spot at the hospital. We then get used to archaic but historical processes, and the thought of changing them seems unnecessary.
We Got Bigger
Many practices start out small and then expand over time. Practices grow by adding more providers, covering more hospitals, and often opening up satellite offices. It is all too common for processes, which were in place when the practice was small, with few moving parts, to be carried forward as the business expands. Unfortunately, the initial workflows in place are rarely scaleable. So new ways of doing things are needed in order to accommodate a more complex environment. Once again, nostalgia wins over innovation, and people have trouble letting go. After all, the original methods worked fine for the founders of the practice, and so why should they change now?
Don’t Take Away My Profession
This problem is more complex. Physicians maintain a certain level of practice individuality, even in today’s micromanaged times. They have different bedside manner, and during a patient encounter are free to care for the patient in their own style. There are similar examples in a medical office where individualization does not impact the overall workflow or other providers.
In contrast, there are many situations where the desire for a personalized process leads to confusion, inefficiency, and eventual employee burnout. Take something as simple as lab results for example. When lab results come in, the doctor must review them and report back to the patient. Now imagine that every doctor has a different process – one wants them printed out, one wants them sent as an electronic message, one writes a narrative of what to say to the patient – you get the idea. The lack of uniformity creates the need for staff to have different ways of carrying out tasks depending on the provider.
As a practice grows, these heterogeneous workflows start to break down. The feeling of being “over-worked” becomes prevalent, which leads to hiring of more staff, and an increase in practice overhead. So when doctors are confronted with the need to standardize certain aspects of the office flow, they tend to stand on the principle of professional individualization, using as references the areas of their practice where there is no standardization (but those areas tend to have no impact on other staff or providers). Convincing doctors to give up their unique methodology in exchange for a singular process is no easy task.
We Can’t Even Order Pizza
I always joke that a room full of doctors could never order pizza together, due to an inability to agree on the toppings. Physicians are strong-minded, well-educated professionals. And there are a lot of toppings. Now ask these same doctors to agree upon a common workflow in the office and you get a stalemate. How, then, do non-medical industries manage to standardize and improve?
Well, there is a well-defined hierarchy that exists in most businesses, and ultimate decision-making is a top-down approach, hopefully with input from the employees doing the work. Medical practices usually have a blurry chain of command, and in many instances, numerous equal partners with equal veto power. Larger practices with a corporate structure have a better chance of implementing process improvement, but there is almost always resistance at some level.
Is There a Solution?
As in most industries, market forces will prevail. Those doctors who wish to remain independent and in private practice face the same challenges of every business: rising costs and the need for growth. The cost of doing business continues to climb, with respect to rent, salaries, benefits and equipment. Human resources is one of the largest expenses for a medical practice other than rent (or mortgage). Creating a lean model with reasonable staff-to-provider ratios is a delicate formula. Too many staff and overhead skyrockets. Too few staff and patient care suffers.
Agreeing upon standardized workflows for the doctors and staff is an effective way of keep employees happy and keep the lean model alive. It may stave off physician burnout as well. If these practices can achieve sustainable and lean processes, the next challenge is scaleability.
Remaining a small practice in today’s medical landscape is getting harder to pull off. Small practices are less likely to secure favorable insurance contracts and hospital alignment due to lack of leverage. If growing the practice to increase market share and influence is the goal, then giving up personalization will be the ultimate realization. Choosing independence with uniformity over employment with loss of professionalization is an easy choice for me, and I hope that more doctors take the necessary steps towards preservation.
About Dr. Greg Sanders
Greg Sanders, MD, FACC is a practicing cardiologist and SaaS entrepreneur. Dr. Sanders received his undergraduate degree and his M.D. from McGill University in Montreal, Canada. After completing his internship and residency at Boston University, he completed a Fellowship in Cardiology at Harvard University. Dr. Sanders is Board Certified in Internal Medicine, Cardiovascular Disease, Echocardiography and Nuclear Cardiology. He has been recognized as one of Phoenix Magazine’s TOP DOCs and practices all aspects of non-invasive cardiology. Dr. Sanders has a special interest in Information Technology and founded HybridChart, a rounding and workflow software solution, which helps specialty practices and providers increase their revenue, streamline their discharge process to improve readmission rates, and ease rounding by having all of their information in one place.